Advocates are attempting more and more to link the Austin homelessness crisis to Texas’ refusal to expand Medicaid through the Affordable Care Act. But the advocates’ proposal is a recipe for disaster that will cause further harm to our neighbors experiencing homelessness, and make it more difficult for the poor to access health care.
The plan is rooted in two myths. First, that expanding eligibility for Medicaid will improve the quality of care received by low-income Texans. Second, that expansion coupled with a housing-first approach will improve outcomes for those experiencing homelessness.
Nationally last year, almost 40 percent of primary care physicians were not accepting new Medicaid patients. Almost 65 percent of psychiatrists were not accepting Medicaid patients, either.
Just because someone has coverage does not mean that they have access to care, or that they will have positive health outcomes. Medicaid is already a strained program, even in a non-expansion state like Texas, where it makes up nearly half of the state’s budget. There are also more than half a million Texans who are currently eligible for Medicaid who have chosen to not enroll. This new block grant does not increase the number of Medicaid-enrolled physicians Texas will have. It also does not mean new practices will open in areas of Texas with lower socio-economic communities.
There is already an existing federal program for those experiencing homelessness to access free, or extremely discounted, health care. Federally Qualified Health Centers (FQHC) are community-based clinics that serve designated medically underserved areas and populations and cannot deny services based on the patient’s ability to pay.
There are more than 40 FQHCs in the Greater Austin area. Some have established programs to provide health care for the homeless. These programs can include substance abuse treatment and mental health services.
Yet utilization of services provided by FQHCs for the homeless, especially substance abuse and mental health treatment, is hampered by the housing-first approach promoted by many advocates. Housing-first, the federal government’s current one-size-fits-all approach to homelessness, requires nonprofits receiving federal funds to adopt so-called “low-barrier” policies. Under housing-first, people experiencing homelessness are provided with subsidized housing without any requirement that they take steps to address the root causes contributing to their situation—steps that can include things such as pursuing employment training, sobriety, or mental health treatment.
It is estimated that 75 percent of unsheltered people struggle with substance use disorders, and nearly 80 percent have a mental health condition. Care is available, but merely providing housing with no requirement for treatment further ensures that these services will go underutilized and those experiencing homelessness will remain trapped in a destructive cycle.
A recent analysis by the United States Interagency Council on Homelessness illustrates how housing-first has contributed to the current homelessness crisis. The administration of President George W. Bush first adopted housing-first as a tool for addressing the most severe cases of chronic homelessness. It was later expanded under President Barack Obama to apply to all people experiencing homelessness between 2011 and 2013. Once federal policy no longer linked housing with services, the USICH analysis shows, street-level homelessness increased by more than 20 percent from 2014 through 2019, after a sustained period of decline in years prior.
The data is clear—merely increasing the number of those with coverage does not create more avenues of access or improve health outcomes.
Likewise, providing someone with a roof over their head without expecting them to take steps to address the underlying causes of their homelessness only exacerbates the problem while robbing them of the opportunity to reach their full potential.